For a tunneled line placement with Interventional Radiology (IR), does the patient need to be Nil Per Os (NPO) and have anticoagulation held?

Tunneled Line Placement Requirements for NPO Status and Anticoagulation

For tunneled line placement with Interventional Radiology (IR), patients should remain NPO (nil per os) for at least 2 hours prior to the procedure, and anticoagulation should be managed based on bleeding risk assessment, with most anticoagulants requiring temporary discontinuation.

NPO Status Requirements

• Patients should be kept nil per os (NPO) past midnight for a procedure scheduled the following day, though clear liquids may be provided up to 2 hours before the procedure to reduce the risk of volume depletion 1
• NPO status is important for procedures involving conscious sedation, which is commonly used during tunneled line placement to improve patient comfort 1
• The dietary preparation helps reduce the risk of aspiration during the procedure, especially if sedation is required 1

Anticoagulation Management

High Bleeding Risk Classification

• Tunneled central venous catheter placement is classified as a category 2 procedure (moderate risk of bleeding) according to Society of Interventional Radiology (SIR) recommendations 1
• For these procedures, anticoagulation management should follow specific guidelines to minimize bleeding risk while preventing thrombotic complications 1, 2

Specific Anticoagulation Recommendations

• INR: If greater than 1.5, correct until it is less than 1.5 1
• Platelets: If platelet count is lower than 50,000/μL, administer transfusion until the count exceeds 50,000/μL 1
• Clopidogrel: Withhold for 5 days before the procedure 1
• Aspirin: No need to withhold 1, 3
• Low molecular weight heparin (therapeutic dose): Withhold one dose before the procedure 1
• Unfractionated heparin: Should be held for the procedure but can be resumed 2-6 hours after completion 1
• Oral anticoagulants: Should be held for placement but can be resumed with the evening dose after placement 1

Evidence Supporting These Recommendations

• Recent evidence suggests that tunneled catheter placement may be classified as having a very low risk of bleeding, with studies showing bleeding rates of less than 0.5% even in patients on antithrombotic medications 3
• The risk of bleeding with tunneled dialysis catheter placement specifically has been reported as 0.36-0.46%, regardless of anticoagulation status 3
• No significant increase in bleeding risk has been reported with dual-antiplatelet therapy continuation during percutaneous enteral tube placement, which has similar bleeding risk profiles 1

Procedural Considerations

• Ultrasound guidance should be used for catheter insertion to minimize complications 1
• A chest X-ray should be obtained promptly after placement and before first use of an internal jugular or subclavian dialysis catheter to confirm proper positioning 1
• The right internal jugular vein is the preferred access site for tunneled catheters due to its more direct trajectory to the cavo-atrial junction and lower risk of complications 1, 4

Common Pitfalls and Caveats

• Failure to properly assess bleeding risk can lead to unnecessary delays in catheter placement or increased risk of bleeding complications 1, 3
• Inadequate NPO status may increase the risk of aspiration during sedation 1
• Laboratory tests (complete blood count, prothrombin time, INR) should be checked before the procedure to assess bleeding risk 1
• Resuming anticoagulation too soon after the procedure may increase the risk of bleeding at the insertion site 1
• Delaying resumption of anticoagulation too long may increase the risk of thrombotic complications in high-risk patients 1, 2